ABC of Evidence-Based Healthcare (eBook)

John Frain (Herausgeber)

eBook Download: EPUB

2025
369 Seiten
Wiley (Verlag)
978-1-394-21933-9 (ISBN)

Infos

ABC of
Evidence - Based Healthcare

A practitioner guide summarizing the aims and achievements of evidence-based healthcare and why it is crucial to modern clinical practice

ABC of Evidence-Based Healthcare explains how evidence is developed and formulated into guidance for clinicians. It details how to interpret and apply this evidence to one's own practice and patients, covering areas such as diagnosis and screening, therapy, harm, and prognosis. Some of the key aspects discussed in this book include understanding choice of study design, the roles of quantitative and qualitative research, selecting and using appraisal tools and key statistical concepts. Additionally, the book also covers how to interpret the results of research studies, apply results to the needs of patients, communicate results to colleagues and incorporate them into student training, as well as discussing treatment options, risks, and benefits with patients.

As in all ABC books, the text is complemented with practical examples of evidence in practice to facilitate understanding. Although a standalone resource in itself, the book signposts readers to useful and comprehensive resources, including web-based calculators and tools for each main theme of the book.

In ABC of Evidence-Based Healthcare, readers will find information on:

• The ethical dimension, philosophy, scope, achievements, and usefulness of evidence-based healthcare
• Pre-appraised versus primary studies, healthcare databases, and search strategies including the use of keywords, wildcards, and filters
• Statistical concepts including probability and confidence intervals, and cohort, diagnostic accuracy, and case control studies
• Bias in research, the impact of under-research, conflicts of interest, and misleading or weak evidence
• Curriculum development, covering objectives and outcomes, curriculum integration, and student assessments

ABC of Evidence-Based Healthcare delivers a practical, accessible, and highly useful introduction to concepts of evidence-based healthcare for students and new practitioners.

Dr. John Frain is a General Practitioner and the Director of Clinical Skills, Division of Medical Sciences and Graduate Entry Medicine at the University of Nottingham, UK.

Textauszug

Chapter 1
What Is Evidence‐Based Healthcare?

John Frain

Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Nottingham, UK

OVERVIEW

• Evidence is the available information or facts which indicate whether a belief or proposition is true.
• Evidence in healthcare is linked to quality, patient safety and improved clinical outcomes.
• The concept of justifying practice through the use of evidence can be found from the earliest times.
• Modern evidence‐based practice has its roots in the development of critical appraisal and modern research methods.
• The ethical dimension is essential in determining the quality and application of evidence.

Introduction

On explaining to a fellow new student on another university course that I was studying evidence‐based healthcare and how to bring evidence into our clinical practice, the alarmed response I received was, ‘You mean healthcare isn’t already evidence‐based?’ It seems obvious that something as important as healthcare should proceed only on the basis of the evidence, given the possible consequences of poor practice. The answer to my colleague’s concern is, of course, both ‘Yes, it is’ and ‘No, it isn’t or rather ‘There is evidence, but it could be better, both in terms of the knowledge and how the knowledge is applied to patient care’. It is always this tension between where practice is now and where it could be in the future, which should motivate both scientists and clinicians to always develop the scope of evidence further in our practice.

Evidence is not only static but also dynamic in the sense our depth of understanding should always be evolving. An example is finger clubbing, first described by Hippocrates in a patient with empyema in the sixth century BCE. Our understanding of clubbing is different from 2500 years ago (Box 1.1).

Therefore, observation is crucial in healthcare because it raises curiosity about the origin of the data, and in this case a physical sign clinicians see in their patients. Hippocrates’ initial observation of a patient’s fingers and his curiosity about a relationship (coincidence, association or causation?) with their empyema has evolved into an evidence‐based physical sign which remains important in physical diagnosis. These clinical questions are vital in clinical reasoning and decision‐making about a patient’s management. They divide into questions about general knowledge of a condition, disease or process (background questions) and specific questions to facilitate clinical decision about the patient in front of us (foreground questions) (Chapter 2) (Box 1.2).

The volume of medical knowledge and belief has evolved immensely. Currently, Medline is adding over a million new records to its database every year. Hippocrates alone wrote around 60 treatises (the Hippocratic Corpus) describing theories of disease, ethical dimensions and approaches to observation and physical examination. Now every busy clinician appreciates the need to access high‐quality information quickly and efficiently for the immediate benefit of patients. The need to summarise evidence and manage changing medical knowledge has been recognised since the seventeenth century with the publication of an abstracting journal in 1682 and the first medical journal in England, Medicina Curiosa, in 1684 (1). The development of indexing, databases and computerisation in the twentieth century has provided the automated databases and evidence retrieval we enjoy now, particularly in the last 30 years. These have facilitated an explosion in the opportunities for a more systematic and rigorous consideration of scientific evidence, which informs clinical practice today (Chapter 3). Many of us will remember the previous challenges of retrieving references for our student essays from the hefty volumes of the Index Medicus, followed by a search of the dusty shelves of a medical library stack room.

Comparing similar groups whose baseline characteristics are similar is particularly important in evaluating a new intervention and is the basis of the randomised controlled trial (RCT). Again, the concept has a long history, with the poet Francisco Petrarch proposing in the fourteenth century that the effects of then‐current treatments for conditions in one group be compared with a similar group of patients in which the natural history of the condition was allowed to proceed unchecked. A famous example is James Lind’s intervention in sailors with scurvy in 1747 (Box 1.3). The first recognised RCT is of the use of streptomycin in the treatment of pulmonary tuberculosis (2). Given the inherent variability of biological systems both individually and in populations, the precise comparison of groups required in accurately evaluating the effectiveness of interventions has led to the development of medical statistics to describe these effects accurately (Chapter 6).

Box 1.1 Understanding the clinical significance of finger clubbing ‘Hippocratic fingers’

Clubbing is characterised by a bulbous swelling of the terminal phalanges of the fingers. It was described first by Hippocrates, who observed it in a patient with empyema. Later it was found to be associated with many conditions, including bronchiectasis, lung cancer, liver cirrhosis, cyanotic congenital heart disease and infective endocarditis. In 1976, South African cardiologist Leo Shamroth observed in his own clubbed fingers an obliteration of the diamond‐shaped spaced normally seen when the dorsal surface of the nails are brought into contact with one another (Shamroth’s sign). A study in JAMA in 2010 found inter‐examiner agreement using Shamroth’s sign on the presence of clubbing to give kappa values of 0.3–0.9 and concluded its use reasonable in the identification of clubbing. Clubbing is present in 1% of patients admitted acutely to acute medical wards and is associated with serious disease in 40% of these patients.

Source: Pallarés‐Sanmartín et al. (20), Vandemergel and Renneboog (21).

Box 1.2 Examples of background and foreground questions

Background questions identify knowledge and understanding of disease processes or clinical conditions. They are often broad in scope and may be answerable from textbooks, general online sources and review articles. They may help information decision‐making about a foreground question and a particular patient but are not the answers in themselves about what is appropriate for a particular patient.

• Example – What is the pathophysiology and prognosis of acute otitis media in children under two years?

Foreground questions require knowledge to assist decision‐making. They may involve a comparison of treatment options, including intervention. Answers to foreground questions require synthesis of primary studies and a comprehensive literature search. These may be used to produce an evidence summary or systematic review.

• Example – Will prescribing oral antibiotics to my 18‐month‐old patient with acute otitis media improve or have any effect on their long‐term prognosis?

Healthcare before evidence‐based healthcare

Evidence existed before the 1990s, and anyone practising in that era knows clinicians both aspired to and did practise scientifically for the benefit of patients. What happened in 1992 and afterwards happened because of what came before, as well as the development of innovative technology and the inspirational leadership of individuals and academic departments in articulating a new vision for the evaluation and application of evidence in healthcare. First is the improvement in the evaluation of interventions and treatments. This has been achieved through better study design, including registration of trials, protocols and promotion of reporting standards (Chapter 4). In addition, the promotion of critical appraisal skills, including in healthcare training programmes, has enabled practitioners to exercise greater reflection and discernment in how to apply evidence to their own patients (Chapters 7 and 8). Even though light‐hearted in tone and certainly not advocated as viable alternatives, Isaacs and Fitzgerald’s perspectives on evidence‐based healthcare were written as a necessary counterpoint to the evidence‐based approach and the issues raised by it. It is worth reflecting on Isaacs and Fitzgerald’s thoughts on alternative methods of clinical decision‐making (Table 1.1). In all things, there should always be a healthy scepticism, if only to encourage necessary questioning and debate to flourish.

Box 1.3 James Lind and comparison of similar groups in the treatment of scurvy

Scurvy results from a lack of vitamin D. It was particularly prevalent in the Royal Navy in the eighteenth century. Provision of citrus fruits to Dutch sailors suggested a reduction in the disease. In 1747, James Lind, a Royal Navy surgeon, selected 12 sailors with scurvy ‘as similar as I could have them’. All sailors received the same diet. The sailors were divided into groups of two. Two were given a quart of cider each day, two took vitriol three times daily, two took...

Produkt-Details

• Erscheint lt. Verlag: 14.2.2025
• Reihe/Serie: ABC Series
• Sprache: englisch
• Themenwelt: Medizin / Pharmazie ► Allgemeines / Lexika
• Schlagworte: evidence based healthcare examples • healthcare appraisal tools • healthcare communication • healthcare practitioner guide • healthcare research • healthcare statistics • healthcare study design • Patient Communication • patients outcomes
• ISBN-10: 1-394-21933-4 / 1394219334
• ISBN-13: 978-1-394-21933-9 / 9781394219339